Tuberculosis In Gastroenterology Practice:

Clinical Challenges

Sanjay Bandyopadhyay

INTRODUCTION

Tuberculosis can involve any part of the gastrointestinal

tract and is the sixth most frequent site of extrapulmonary

involvement 1 . Both the incidence and severity of
extrapulmonary tuberculosis are expected to increase
with increasing incidence of human immunodeficiency
virus (HIV) infection 2. Tuberculosis that is encountered
in Gastroenterology practice denotes involvement of the
gastrointestinal tract, peritoneum, lymph nodes, and
solid viscera, e.g. liver, spleen, pancreas. In decreasing
order, gastrointestinal localizations include: the ileocecal
region, the ascending colon, the jejunum, the appendix,
the duodenum, the stomach, the esophagus, the sigmoid
colon, and the rectum3.
It is predominantly a disease of young adults. Two third
of patients are 21- 40 years old. Sex incidence is equal
though some studies from India have shown a female
preponderance2,4. The spectrum of disease in children is
different, in whom adhesive peritoneal & lymph nodal
involvement is more common 5.
The clinical presentation can be acute, chronic, or acute-onchronic. On the other hand, diagnosis may be an incidental
finding at laparotomy for other diseases - usually peritoneal
or lymph nodal 6.
CLINICAL FEATURES
Most patients present with constitutional symptoms and
fever is present in 40-70%. Fever is usually low-grade with
evening rise, lethargy, malaise, night sweats, anorexia
and weight loss (failure to thrive in children). Other

manifestations depend on the organ involved. The chief

presenting complaints of abdominal tuberculosis include
abdominal pain in 80- 90%, diarrhea in 11-20%, constipation,
alternating constipation & diarrhea, weight loss (40- 90%),
anorexia and malaise. Constitutional symptoms are more
frequent in those with ulcerative intestinal lesions and
ascitic peritoneal tuberculosis. Pain can be either colicky
due to luminal compromise, or dull and continuous when
the mesenteric lymph nodes are involved. Some patients,
particularly those with associated miliary tuberculosis, may
have tubercular toxaemia with high fever, tachycardia,
anaemia, and leucocytosis.
Tuberculous involvement of other organs or systems has
been reported in as many as one-third of patients 7. Common
sites of involvement are pulmonary and pleural. Genital
tract involvement has been reported in 10% of women with
abdominal tuberculosis 8. Peripheral lymph nodes (cervical
or axillary) may be involved in 3-10% of patients 9. A family
history of tuberculosis is rarely revealed by patients in India
because of the social stigma still attached to the disease2.
ESOPHAGEAL TUBERCULOSIS
Esophageal tuberculosis is a rare entity constituting 0.2%
cases of GI tuberculosis. Presenting features are fever,
dysphagia (82%), odynophagia, and haematemesis (18%).
The most common feature is extrinsic compression of the
oesophagus usually by a mass of tuberculous lymph nodes10.
When the process involves the oesophageal mucosa an
exuberant tumorous lesion or an ulcer may result, both of
which are radiographically indistinguishable from carcinoma.

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The contrast oesophagogram may demonstrate a sinus into

the mediastinum or a fistula into the tracheobronchial
tree. A constrictive lesion may result which may be
radiographically indistinguishable from the more common
causes of benign oesophageal stricture. Mid-esophageal
ulcer is most commonly noted on endoscopic evaluation
when the disease masquarades as esophageal carcinoma.
The outcome of medical treatment is very rewarding and
90% have an uneventful recovery. Symptoms subside fairly
rapidly and the oesophagogram reverts to normal within
three months of treatment in most cases 11.
GASTRIC TUBERCULOSIS
Stomach and duodenum comprises 1% each of abdominal
tuberculosis. The rarity of gastric tuberculosis is due to
gastric acid, continuous motor activity of the stomach and
the scarcity of lymphatic follicles in the gastric wall 12.
Long-term therapy with H2 blockers increases the incidence
of gastro-duodenal tuberculosis 13. Gastric tuberculosis
usually develops secondary to other tuberculous lesions,
most commonly pulmonary. The antrum and prepyloric
regions are the most common sites 14 . The clinical
manifestations are nonspecific and the diagnosis is often
missed. It can present as pyrexia of unknown origin, gastric
outlet obstruction, benign peptic ulcer, haematemesis and,
rarely perforation. Short duration of history, early onset of
obstruction, bizarre endoscopic findings, and non-response
to anti-secretory therapy in a patient with a diagnosis of
peptic ulcer should arouse the suspicion of gastroduodenal
tuberculosis 1. Gastric tuberculosis may simulate gastric
carcinoma. The diagnosis can only be made by histological
study of the resected stomach or of a biopsy specimen
showing caseous or non-caseous granuloma. Non-caseating
granulomas are also caused by Crohns disease (CD),
sarcoidosis and idiopathic granulomatous gastritis 12. Clinical
and other histopathological features and culture help in
differentiation.
DUODENAL TUBERCULOSIS
The major presenting features of duodenal tuberculosis
are vomiting (due to gastric outlet obstruction; in 61%),
epigastric pain (56%), loss of appetite (30%), upper GI
bleeding (26%), fever (9%), jaundice (9%) and recurrent
cholangitis (4%) 15. Rare fistulous communications with bile
duct or aorta have been reported 16. In nearly 13%, clinical,
radiological and intraoperative features suggest malignancy/
pseudotumor and only 23% had extragastrointestinal
involvement. Despite upper GI endoscopy and biopsies, the
preoperative diagnosis is correct for only 10%. However,

most common cause of duodenal obstruction in abdominal

tuberculosis is extrinsic compression by lymph nodes.
Barium studies reveal evidence of segmental narrowing.
Duodenal strictures are usually short but can involve long
segments of the duodenum. Computed tomography (CT) may
reveal wall thickening and/or lymphadenopathy. There is no
specific picture of duodenal tuberculosis on endoscopy, and
demonstration of granulomas or acid fact bacilli (AFB) on
endoscopic biopsy material is unusual. When diagnoses of
TB are established before surgery, most lesions regress with
appropriate antitubercular treatment and do not require
excision. Even in patients with strictures, endoscopic balloon
dilatation has been successful 17. Elective surgery should
be reserved for complications such as obstruction, fistula
formation or intractable ulceration.
INTESTINAL TUBERCULOSIS
Intestinal tuberculosis often occurs in the ileocaecal region
(52%-85%). The hypertrophic form is the most common
type, and, because it tends to constrict the lumen, patients
present with features of intestinal obstruction such as
colicky abdominal pain, borborygmi, vomiting 1. Symptoms
and signs of intestinal tuberculosis are non-specific making
accurate diagnosis difficult (34% to 50% accuracy of clinical
findings). Par abdominal examination may reveal a classic
doughy feel (in 10-20% only), though at times examination
may be unrevealing as well. A well-defined, firm, usually
mobile mass is often palpable in right lower quadrant.
Presence of mobile lump signifies involvement of mesenteric
nodes whereas fixed lump indicates involvement of paraaortic or iliac group of nodes 6.
Tuberculosis & intestinal obstruction
The most common complication of small bowel or ileocaecal
tuberculosis is obstruction due to narrowing of the lumen by
hyperplastic caecal tuberculosis, by strictures of the small
intestine, which are commonly multiple, or by adhesions
18
. Adjacent lymph nodal involvement can lead to traction,
narrowing and fixity of bowel loops. In India, 3-25% of all
cases of bowel obstruction are due to tuberculosis, while the
incidence of intestinal obstruction due to tuberculosis ranges
from 12% to 60% 19. Intestinal obstruction in tuberculosis is
usually chronic/ subacute but may be acute-on-chronic.
Tandon et al observed an increase in patients with more
protracted course and subacute intestinal obstruction in
recent years 20.
Tuberculosis & intestinal perforation
Tuberculosis accounts for 5-9% of intestinal perforations

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323

and is second only to typhoid as the etiology of perforation

in India 21. Evidence of tuberculosis in chest radiograph
(CXR) & subacute presentation are important clues to
diagnosis. Pneumoperitoneum is found in 50%. Tubercular
perforations are usually single & proximal to a stricture 22.
Acute tubercular peritonitis without perforation is usually
an acute presentation of peritoneal disease but may be due
to ruptured caseating lymph nodes.

also need to be freed in order to relieve the obstruction, and

hence, the potential for iatrogenic complications is high.
Acute tubercular abdomen It may present in following
ways1:
1) Intestinal obstruction: acute or acute-on-chronic
2) Peritonitis: with or without perforation
3) Acute mesenteric lymphadenitis
4) Acute tubercular appendicitis

Tuberculosis & malabsorption

Tuberculosis of intestine is a common cause of malabsorption
in India, next only to Tropical spure 23. Concurrence of
abdominal pain with features of malabsorption is a pointer
towards the tubercular etiology. Malabsorption is more
commonly found in those with strictures (75%), compared
to non-stricturing form (40%) 24. The postulated causes of
malabsorption are: bacterial overgrowth proximal to a
stricture, bile salt deconjugation, diminished absorptive
surface, involvement of lymphatics & lymph nodes.

Segmental colonic tuberculosis

Segmental or isolated colonic tuberculosis refers to
involvement of the colon without ileocaecal region, and
constitutes 9.2% of all cases of abdominal tuberculosis 26.
It commonly involves the sigmoid, ascending and transverse
colon. Multifocal involvement is noted in one-third. Median
duration of symptoms is one year. Pain is the commonest
presenting symptom (78-90%), followed by hematochezia usually minor (33%). Mucosal nodules of variable sizes (2-6
mm) & ulcers in a discrete segment of colon, 4-8 cm in
length are pathognomonic 27.

Tuberculosis and abdominal cocoon (AC)

AC is characterized by partial or total encasement of the
small gut by a fibrocollagenous sac that looks like a cocoon.
The patient may present with signs and symptoms of acute,
subacute or chronic intestinal obstruction, abdominal
distension, weight loss or a mobile abdominal mass 25.
The classic barium finding is a serpentine or concertinalike configuration of dilated small bowel loops in a fixed
U-shaped cluster or a cauliflower sign, but these are
not always present and are nonspecific. Delayed transit is
more diagnostic. A typical picture on CT is a concentration
of a part of or the entire small bowel in the center of the
abdomen encased by a soft tissue-density mantle (Fig.1).
Ascites is uncommon. At surgery, in addition to the covering
membrane, there also are dense interbowel adhesions that

Differential diagnosis of colonic tuberculosis includes

Crohns colitis, Ulcerative colitis (UC) and colon carcinoma.
Colonic tuberculosis involves area around the hepatic
flexure, presents with pain abdomen and minor bleeding.
Pathologically they have transverse/linear ulcers, ulceration
with stricture, long segment stricture, mucosal fibrous
strands. Gut wall is asymmetrically thickened with
mesenteric nodes.
Crohns colitis usually involves the cecum. Other than pain
abdomen, they usually have occult GI bleed. Serpeginous
ulcer, ulceration with stricture, multiple short strictures
are noted. Mesenteric nodes are also found but gut wall
thickening is symmetric.
UC predominantly involves rectum and presents with bloody
diarrhoea. Endoscopically confluent ulcers are seen in a
continuous manner. Gut wall thickening and stricture is
distinctly uncommon.
In carcinoma of the colon, patients presents with change
in bowel habit or hematochezia. They may have large
excavating ulcer with stricture or single short stricture.
Gut wall may have variegated appearance, with hepatic
metastasis and retroperitoneal lymphadenopathy.

Fig.1: Contrast-enhanced CT images show congregated

small gut loops confined to a single area and encased
in a thick membrane

Rectal Tuberculosis
It is a rare presentation of abdominal tuberculosis. Presenting

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features are hematochezia (88%), constitutional symptoms

(75%), constipation (37%) and rarely fistula 28. Annular tight
long stricture with focal areas of deep ulcerations occurs
usually within 10 cm of anal verge 29. Associated perianal
disease is very rare - a distinguishing feature from CD.
Anal Tuberculosis
Anal tuberculosis presents with fistulae (more commonly
multiple) and they constitute 14% of all fistula-in-ano 30.
Anal discharge is present in all of them whereas perianal
swelling is found in one-third 30. Constitutional symptoms are
classically absent in anal tuberculosis. Pediatric population
has greater incidence of anal tuberculosis compared to
adults.
Investigative procedures in intestinal tuberculosis
Plain X-ray abdomen: Plain X-ray abdomen may show
enteroliths, features of obstruction i.e., dilated bowel loops
with multiple air fluid levels, perforation or intussusception.
In addition, there may be calcified lymph nodes or calcified
granulomas in liver/spleen.
Small bowel series: Barium meal follow through (BMFT) is
better for evaluation of small bowel mucosa while small
bowel enema (i e barium enteroclysis) may be more useful
in distal obstructive (stricturing) lesion. Barium enema is
reserved for evaluating ileocaecal and colonic disease. The
features which can be seen on barium are: accelerated
intestinal transit, hypersegmentation of the barium
column (chicken intestine), precipitation, flocculation
and dilution of the barium, stiffened and thickened folds,
luminal stenosis with smooth but stiff contours (hour glass
stenosis), multiple strictures with segmental dilatation of
bowel loops, and fixity and matting of bowel loops.
Several classic radiographic signs of ileocaecal tuberculosis
are 31:
1. Fleischner or inverted umbrella sign (Fig.2A): Thickening
of the lips of the ileocaecal valve and/or wide gaping of
the valve with narrowing of the terminal ileum
2. Conical caecum (Fig.2B): shrunken in size and pulled out
of the iliac fossa due to contraction and fibrosis of the
mesocolon. The hepatic flexure may also be pulled down
3. Goose neck deformity (Fig.2C): Loss of normal ileocaecal
angle and dilated terminal ileum, appearing suspended
from a retracted, fibrosed caecum
4. Purse string stenosis: Localized stenosis opposite the
ileocaecal valve with a rounded off smooth caecum and
a dilated terminal ileum
5. Stierlins sign (Fig.2D): Lack of barium retention in the

Fig.2: Small bowel series showing inverted umbrella

sign (A), conical caecum (B), goose-neck deformity (C),
and Stierlin sign (D)
inflammed segments of the ileum, caecum and variable
length of the ascending colon, with a normal configured
column of barium on either side
6. String sign - Persistant narrow stream of barium indicating
stenosis
Enteroclysis followed by a barium enema may be the best
protocol for evaluation of intestinal tuberculosis. Similar
radiological features are demonstrated in CD, lymphoma,
amebiasis, carcinoma and even sarcoidosis. Radiological
differentiation of early-stage ileocaecal tuberculosis from
Crohns disease and lymphoma is usually impossible.
Computed tomography (CT) scan: Ileocaecal tuberculosis
is usually hyperplastic and well evaluated on CT scan. In
early disease, there is slight symmetric circumferential
thickening of caecum and terminal ileum. Later the
ileocaecal valve and adjacent medial wall of the caecum is
asymmetrically thickened. In more advanced disease gross
wall thickening, adherent loops, large regional nodes and
mesenteric thickening can together form a soft tissue mass
centered around the ileocaecal junction 32. CT scan can

Medicine Update-2011

also pick up ulceration or nodularity within the terminal

ileum, along with narrowing and proximal dilatation. Other
areas of small and large bowel involvement manifest as
circumferential wall thickening, narrowing of the lumen and
ulceration. In the colon, involvement around the hepatic
flexure is common. Complications of perforation, abscess,
and obstruction are also seen on CT.
Table I shows specificity of various imaging modalities
in detecting specific changes encountered in abdominal
tuberculosis 33.
Colonoscopy: Colonoscopy is an excellent tool to diagnose
colonic and terminal ileal involvement. Pink non-friable
mucosal nodules of variable sizes (2 to 6 mm) and
transversely-oriented ulcers in a discrete segment of colon,
4 to 8 cm in length, are pathognomic. The intervening
mucosa may be hyperemic or normal. Areas of strictures with
nodular and ulcerated mucosa may be seen. Other findings
are pseudopolypoid edematous folds, and a deformed
and edematous ileocaecal valve. Diffuse involvement of
the entire colon is rare (4%) 34. Most workers take up to
8-10 colonoscopic biopsies from the edge of the ulcers for
histopathology and culture. However, there is a low yield
on histopathology because of predominant submucosal
involvement. Granulomas have been reported in 8-48% of

patients with caseation in a third of them 27. Endoscopic

mucosal biopsies are useful to differentiate CD from
tuberculosis 35. In addition, in-situ polymerase chain reaction
(PCR) using Mycobacterium tuberculosis complex-specific
primers for IS6110 has been recently validated 36.
Intestinal tuberculosis vs Crohns disease
Abdominal tuberculosis should be considered in any
whenever a diagnosis of CD is being entertained. In case of
misdiagnosis of tuberculosis, unnecessary anti-tubercular
therapy (ATT) poses a risk of toxicity and treatment of the
primary disease, i.e. CD is delayed. In contrast, treatment
with steroids alone (for CD) can be disastrous, if diagnosis
of tuberculosis is missed.
In a recent study, Lee et al. reported that their diagnosis
was correct in 87.5 % of patients when the diagnosis was
made on the basis of four features, namely anorectal lesions,
longitudinal ulcers, aphthous ulcers and cobblestoning for
CD and involvement of less than four segments, patulous
ileocecal valve, transverse ulcers, and pseudopolyps for
intestinal tuberculosis 37. In an Indian study, prolonged
duration of illness (58 months versus 7 months), diarrhea,
hematochezia, extraintestinal manifestations - all were
more common in CD. On the other hand, fever & ascites
were more commonly found in tuberculosis 38.

Table I. Specificity of various imaging modalities in detecting specific changes encountered in abdominal
tuberculosis
Involved organ
Peritoneum and its reflections

Lymph nodes
Solid organs

GI tract

Findings
Ascites
Septa
Slight peritoneal thickening
Tiny nodules
Peritoneal enhancement
Omental changes
Mesenteric changes
Node enlargement
Node characteristics
Hepatosplenomegaly
Bright liver-spleen
Macronodules (liver-spleen)
Pancreatic lesions
Ulcers
Irregular-narrowed segment
Wall thickening
Regional lymph nodes
Regional fast involvement

325

GI series
++
++
-/+
-

US
++
++
++ (if ascites +)
++ (if ascites +)
+
+
+
+
++
++
++
+
-/+
+
+
+
-

CT
++
-/+
++
++
++
++
++
++
++
++
++
++
+
++
++
++
++

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In a multivariate analysis by Makharia et al, blood in

stool, weight loss, involvement of sigmoid and focallyenhanced colitis were found to be independent predictors
for a diagnosis of intestinal tuberculosis 39. The Regression
Coefficients of the final multivariate logistic model were
taken as weights for the respective variables and the score
was calculated for each patient. A constant of 7 was added
to make the score positive.
Score = - 2.5 involvement of sigmoid colon - 2.1 blood
in stool+2.3 weight loss - 2.1 focally enhanced colitis+7
The score varied from 0.3 to 9.3. Higher score predicted
more likelihood of intestinal tuberculosis. The predictive
accuracy of the score was nearly 91%.
However, in a study from China in 2006, the authors did not

find any significant difference in the clinical, endoscopic,

and radiological features between tuberculosis and CD 40.
The prevalence of positive anti-Saccharomyces cerivisiae
(ASCA) is much lower in CD in India compared to West
and serological markers of CD (ASCA) are not significantly
different between CD and GI tuberculosis 41.
The differentiating points between intestinal tuberculosis
and Crohns disease are summarized in Table II 42.
ABDOMINAL LYMPHADENOPATHY
Presentation of tubercular lymphadenoapthy is varied
and may be in the form of fever (pyrexia on unknown
origin), pain abdomen, intestinal obstruction or lump
(usually associated gut/mesenteric involvement) 1. The
important differential diagnoses in this case would be

Table II. Differentiation of Crohns disease (CD) from intestinal tuberculosis (IT)
Parameter
Age (years)
Gender (male-female)
Partial intestinal obstruction
Anorectal disease
Fistulae
Colonoscopy / endoscopy
Ulcers

Cobblestoning
Ileo-cecal valve
Segmental colitis
Barium radiology
Strictures
Skip lesions
CT/MRI abdomen
Wall thickening
Mesentery
Lymph node enlargement
Ascites
Endoscopi biopsy / histopathology
Granulomas
Caseation
Confluent granulomas
>5 granulomas/site
Large granulomas (>400 m)
Submucosal granulomas
Disproportionate submucosal inflammation
Acid-fast bacilli (AFB) on smear
TB DNA analysis positive

CD
20-50
3:1
Occassional
~25%
Common

IT
Any age
1:3
Frequent
~8%
Rare

Longitudinal orientation
Adjacent mucosa normal
Aphthous ulcers common
Frequent
Preserved architecture
~80%

Circumferential orientation
Adjacent mucosa inflammed
Apthous ulcers uncommon
Hyperemic nodules
Destroyed in 80%
~40%

Long
Often multiple
Frequent

Short
Usually single
Rare

Symmetric
Creeping fat or comb sign
Usually regional, 3-8 mm
Homogenous enhancement
Rare

Asymmetric
Nodularity, abscesses, caked omentum
Regional and / or retroperitoneal, 12-550 mm
Enhancing rim with central low attenuation
Common

30-60%
0
0
0
0
5-6%
5-10%
0
0-5%

80-100%
~40%
40-60%
40-45%
50%
40-45%
~65%
~30%
22-75%

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metastatic malignancy, lymphoma, and HIV infection.

Various imaging techniques can lend some help for clue to
diagnosis. In ultrasound examination lymphadenopathy is
shown to be conglomerated mass with mixed heterogenous
(homogenously hypoechoic in lymphoma) echo pattern,
along with small discrete anechoic areas (representing
caseation), often calcified (unusual in malignancy) 43. A
paradoxical response with transient increase in size for
3-4 weeks with treatment can be observed in tubercular
lymphadenopathy. Associated mesenteric or bowel wall
thickening - best appreciated in ileocecal region, provides
additional clue towards tubercular etiology. On contrastenhanced CT scan of abdomen, caseating lymph nodes of
tuberculosis appear as nodes with hypodense center and
peripheral ring enhancement (Fig.3). Calcification may
be occasionally found. The mesenteric, celiac, porta,
peripancreatic nodes are characteristically involved in
tubercular pathology. On the contrary, retroperitoneal
(periaortic & pericaval) nodes are relatively spared (usually
involved in lymphoma)32.
PERITONEAL TUBERCULOSIS
Peritoneal tuberculosis accounts for 0.5 -1% of all
tuberculosis-related hospital admissions with an overall
mortality rate of 7% 44.
Sanai et al presented cumulative data on clinical features
compiled from 35 studies of tuberculous peritonitis45.
Abdominal pain is a common (65%) presenting symptom

327

and frequently accompanied by abdominal distension. It is

usually non-localized and vague in nature. The pain is largely
due to the tuberculous inflammation of the peritoneum
and mesentery. Less often, it could be a manifestation of
intermittent subacute intestinal obstruction. Other features
include: fever (59%), diarrhea (61%), weight loss (21%)
and constipation (11%). On examination, ascites (73%),
abdominal tenderness (48%), hepatomegaly (28%) and
splenomegaly (14%) are found in varying combinations 45.
Ascitic fluid in peritoneal tuberculosis is usually of strawcolored with total protein content > 3 g/dl, and total cell
count ranges from 150-4000/cmm with predominance of
lymphocytes (>70%) 1. Characteristically it is low serumascitic albumin gradient (SAAG) (< 1.1 g/dl) ascites.
Bacteriological proof for definitive diagnosis can be done by
Ziehl-Neelsen (Z-N) staining or culture of ascitic fluid. Low
yield of these procedures are the drawback. (AFB staining:
3%, positive culture : 20%) 1. Culture of one liter of ascitic
fluid after centrifugation can increase the yield to 83% 46.
Ascitic fluid ADA has been studied for diagnosis of tubercular
peritonitis. Sensitivity and specificity levels are over 90%
and an ascitic fluid ADA activity of >33 U/L is generally
accepted as the cut-off level to yield the best results 47.
Bhargava et al showed that serum ADA > 54 IU/L, ascitic
fluid ADA >36 IU/L, and a ascitic fluid : serum ADA > 0.985
correlate well with tubercular etiology 48. However, in HIV
co-infection, ADA values may be falsely low. Combining ADA
with IFN- may increase the diagnostic yield 49. An ascites :
blood glucose ratio < 0.96 may also suggest tuberculosis.50 .
Presence of low SAAG ascites narrows down the possibilities
into situations such as malignancy and tuberculosis. Time
course of the diseases and the physical findings in these cases
closely resemble. Poor yield of malignant cells in ascitic
fluid makes it difficult to differentiate between these two
entities. We evaluated biochemical parameters of ascetic
fluid with an aim to differentiate between the two, and
found that ascitic fluid LDH <110 U/L and ADA >33 U/L has a
sensitivity of 97% and specificity of 100% for tuberculosis51.

Fig.3: Multiple enlarged retroperitoneal and

mesenteric lymph nodes with characteristics
hypodense centers and peripheral rim enhancement
are seen on CECT

Ultrasonography (USG) shows intra-abdominal fluid which

may be free or loculated; and clear or complex (with debri
and septae). Fluid collections in the pelvis may have thick
septa and can mimic ovarian cyst (Fig. 4). Club sandwich
sign is characteristic on CT. CT is more sensitive than USG
(Table I).

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III 52. Although abnormal liver function tests are found

in majority, especially in those patients with obstructive
jaundice, they were non-specific and, thus, not diagnostic of
hepatobiliary tuberculosis. Small discrete scattered hepatic
calcifications on plain abdominal radiograph may be found
up to 50% cases52.
Table III. Outstanding symptoms and signs of
hepatobiliary tuberculosis from four large series

Fig.4: Sonogram of right lower quadrant of abdomen

reveals adhesions that are composed of free strands
of deposited fibrin forming a lattice-like appearance
Laparoscopy is the diagnostic tool of choice in patients
with suspected tubercular peritonitis. The cumulative
data of 402 patients from 11 studies showed impressive
sensitivity and specificity rates of 93% and 98% respectively
when the macroscopic appearances are combined with the
histological findings (epitheloid granuloma with caseation
or Mycobacterial identification) 45.
HEPATOBILIARY TUBERCULOSIS
Hepatobiliary tuberculosis can present in one of the
following three ways 52:
1) As a part of miliary form
2) Granulomatous disease (tuberculous hepatitis):
unexplained fever with or without hepatomegaly
3) Localized hepatic tuberculosis - this can be again in two
forms
(a) without bile duct involvement - here presentation can
be with solitary or multiple nodules, tuberculoma of
liver or in the form of tuberculous hepatic abscess
(b) with bile duct involvement - here enlarged lymph
nodes surrounding ducts compress the bile ducts and
causes inflammatory strictures.
Male are twice as commonly affected compared to females
and the usual age of presentation is between 30-50 years.
Impressive data from four case series are listed in Table

Chronic recurrent obstructive jaundice is another mode of

presentation where patients usually have their symptoms
for more than one year, examination finding often includes
an enlarged, nodular liver, imaging reveals presence of
scattered hepatic calcification with tight hilar stricture and
calcified lymph nodes alongside the stricture.
It is the imaging modalities that gives clue to hepatobiliary
tuberculosis in a given setting and also helps to differentiate
it from other pathologies.
In hepatobiliary tuberculosis, large chalky and confluent
hepatic calcifications are seen (Fig.5). Other characteristic
imaging finding is the nodal-type calcifications along
the course of the common bile duct 53. Histoplasmosis is
differentiated from tuberculosis by the presence of small,
discrete, scattered calcifications. Benign tumors of liver
may show popcorn calcification. Liver cysts show marginal
calcification. Primary hepatocellular carcinoma are usually
solitary and show irregular calcification if any. On the other
hand calcification is unusual in hepatic metastasis.
On the basis of transabdominal ultrasound, it is difficult
to differentiate carcinoma from localized hepatobiliary
tuberculosis as the later may show hypo-echoic lesions and
complex masses similar to malignant neoplasia 32. CT scan

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329

rim enhancement in the peri-pancreatic region and/or

mesentery, ascites and/or mural thickening affecting the
ileo-caecal region 56. It should be suspected clinically
in patients with a pancreatic mass, particularly if the
patient is young, not jaundiced, coming from an area of
high tuberculosis endemicity and having a normal ERCP.
About 50% are seropositive for HIV and 40% has history of
tuberculosis of the lungs 57. USG shows bulky inhomogenous
pancreas, solitary or multiple hypoechoic collections. CT
finding demonstrates hypodense collections within the
pancreas associated with peripancreatic lymphadenopathy
in majority. Pancreatic tuberculosis should be considered
as a differential diagnosis of a pancreatic mass and most
patients have an excellent clinical response to standard
antitubercular regimens.

Fig.5: Plain scout film of the abdomen showing hepatic

calcification with confirmed hepatobiliary tuberculosis
is also insufficient to distinguish solitary or multiple focal
masses due to a large tuberculoma or tuberculous abscess
from malignancy.
The diagnosis of hepatobiliary TB in endemic areas/countries
should be considered in cases of unexplained hepatomegaly,
especially if accompanied by weight loss and fever, if there is
associated pulmonary TB by CXR, in presence of an enlarged,
hard nodular liver, especially if present for more than one
year and if scattered hepatic calcifications are found in
imaging modalities 54.
PANCREATIC TUBERCULOSIS
Tuberculosis of pancreas more commonly presents as
carcinoma, pancreatitis, or abscess and mostly they are
diagnosed post-operatively. They account for 8.33% of
cases of abdominal tuberculosis 55. The mean age is 42.5
years (range 19 to 64 years) with male: females ratio of
2.2:1. Mean duration of symptoms is 6 months (2 to 11
months). Pancreatic tuberculosis presents with a wide
spectrum of symptoms such as abdominal pain (nearly
all), constitutional symptoms such as anorexia, weight
loss and night sweat, fever, obstructive jaundice, iron
deficiency anemia, pancreatic abscess, massive gastrointestinal bleeding, acute or chronic pancreatitis, secondary
diabetes, splenic vein thrombosis, and a pancreatic mass
mimicking malignancy. Radiological indicators leading
to the diagnosis of pancreatic tuberculosis include the
presence of characteristic hypo-dense lymph nodes with

ROLE OF SEROLOGY IN THE DIAGNOSIS OF TUBERCULOSIS

Serological tests (including Enzyme linked immunosorbent
assay for IgG, IgM and IgA) produce highly variable
sensitivity and specificity results and therefore cannot
be recommended as a sole test for the diagnosis of
extrapulmonary tuberculosis. It is particularly disappointing
that there are no studies that are of sufficient quality to
enable their evaluation in patients with HIV infection or in
children. In addition, most of these remain positive even
after therapy, the response to Mycobacteria is variable and
their reproducibility is poor. Overall the value of serological
tests remains undefined in clinical practice 58.
TREATMENT
All patients should receive conventional ATT therapy for at
least six months including initial two months of rifampicin,
isoniazid, pyrazinamide and ethambutol1,2. Balasubramanium
et al reported that a six-month four drugs short course
chemotherapy is as efficacious as twelve month course of
ethambutol and isoniazid (supplemented by streptomycin
for first two months) 59. However many physicians extend
the treatment duration to 12 to 18 months.
The recommended surgical procedures today are
conservative. A period of pre operative drug therapy is
controversial. Strictures which reduce the lumen by half
or more and which cause proximal hypertrophy or dilation
are treated by strictureplasty 60. This involves a 5-6 cm
long incision along the anti-mesenteric side which is closed
transversely in two layers. A segment of bowel bearing
multiple strictures or a single long tubular stricture may
merit segmental resection. For tubercular perforations,
resection and anastomosis is preferred as simple closure

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Medicine Update-2011

is associated with a high incidence of leak and fistula

formation. Obstructing intestinal lesions may relieve with
antitubercular drugs alone without surgery 61. Predictors of
need for surgery are long strictures (>12 cm) and multiple
areas of involvement.
PROGNOSIS
Delayed diagnosis and injudicious treatment are principally
responsible for the mortality rate of 4-12% 22. The high
mortality is partly due to the associated malnutrition,
anaemia and hypoalbuminaemia; mortality is even higher
(12-25%) in the presence of acute complications. Timely
diagnosis based on a high index of suspicion in areas and in

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Of major importance
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